Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.6 Attention Deficit/Hyperactivity Disorder

ylphenidate, the d-enantiomer (Focalin), and its longer acting form Focalin XR. These newer preparations aim to maximize the target effects and minimize the adverse effects in individuals with ADHD who obtain partial response from methylphenidate or whose dose was limited by side effects. Vyvanse (lisdexamfe- tamine dimesylate) is a pro-drug of dextroamphetamine, which requires intestinal metabolism in order to reach its active form. Vyvanse is approved by the U.S. Food and Drug Administration (FDA) for children 6 years and older. Vyvanse, inactive until it is metabolized, is a less likely agent to have risks of abuse or overdose. It has side effects and efficacy similar to the other forms of amphetamines used in the treatment of ADHD. Current strategies favor once a day sustained-release stimu- lant preparations for their convenience and diminished rebound side effects. Advantages of the sustained-release preparations for children are that one dose in the morning will sustain the effects all day, and the child is no longer required to interrupt his or her school day, as well as the physiologic advantage that the medication is sustained at an approximately even level in the body throughout the day so that periods of rebound and irritabil- ity are avoided. Table 31.6-2 contains comparative information on the above medications. Nonstimulant medications approved by the FDA in the treat- ment of ADHD include atomoxetine (Strattera), a norepineph- rine uptake inhibitor. Unlike the stimulants, Strattera carries with it a black box warning for potential increases in suicidal thoughts or behaviors and requires children with ADHD to be monitored for these symptoms, similarly to children who are administered antidepressants. A-agonists including clonidine (Catapres) and guanfacine (Tenex) have also been found to be effective in treating ADHD. The FDA has recently approved the extended-release forms of clonidine (Kapvay) and the extended release form of guanfacine (Intuniv) for the treatment

Children with both ADHD and conduct disorder are also at risk for developing substance use disorders. The development of substance abuse disorders among ADHD youth in adolescence appears to be more related to the presence of conduct disorder rather than to ADHD. Most children with ADHD have some social difficulties. Socially dysfunctional children with ADHD have significantly higher rates of comorbid psychiatric disorders, and experience more problems with behavior in school as well as with peers and family members. Overall, the outcome of ADHD in child- hood seems to be related to the degree of persistent comorbid psychopathology, especially conduct disorder, social disability, and chaotic family factors. Optimal outcomes may be pro- moted by ameliorating children’s social functioning, dimin- ishing aggression, and improving family situations as early as possible. Treatment Pharmacotherapy.  Pharmacologic treatment is considered the first line of treatment for ADHD. Central nervous system stimulants are the first choice of agents in that they have been shown to have the greatest efficacy with generally mild tolerable side effects. Stimulants are contraindicated in children, adoles- cents, and adults with known cardiac risks and abnormalities. In medically healthy youth, however, excellent safety records are documented for short- and sustained-release preparations of methylphenidate (Ritalin, Ritalin-SR, Concerta, Metadate CD, Metadate ER), dextroamphetamine (Dexedrine, Dexedrine spansules, Vyvanse), and dextroamphetamine and amphetamine salt combinations (Adderall, Adderall XR). Newer preparations of methylphenidate, include Methylin, a chewable form of meth- ylphenidate; Daytrana, a methylphenidate patch; and dexmeth-

Table 31.6-2 Stimulant Medications in the Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD)

Medication

Preparation (mg)

Approx. Duration (hr)

Recommended Dose

Methylphenidate preparations Ritalin

5, 10, 15, 20

3 to 4

0.3–1 mg/kg t.i.d.; up to 60 mg/day

Ritalin-SR Concerta

20

8

Up to 60 mg/day Up to 54 mg/q am

18, 36, 54

12

Metadate ER Metadate CD Ritalin LA Methylin Daytrana Patch

10, 20

8

Up to 60 mg/d

20

12

Up to 60 mg/q am

5, 10, 15, 20 5, 10, 20 10, 20, 30

8 3–4 12

Up to 60 mg/day 0.3–1 mg/kg t.i.d. up to 60 mg/day 30 mg/day

Dexmethylphenidate preparation Focalin

2.5, 5, 10 5, 10, 20

3 to 4 6 to 8

Up to 10 mg/day Up to 20 mg/day

Focalin XR

Dextroamphetamine preparations Dexedrine 5, 10

3 to 4

0.15 to 0.5 mg/kg b.i.d.; up to 40 mg/day

Dexedrine Spansule

5, 10, 15 20,30, 40,50,60, 70

8 12

Up to 40 mg/day Up to 70 mg/d; once daily

Lisdexamfetamine Vyvanse

Combined Dextroamphetamine/amphetamine salts Adderall 5, 10, 20, 30

4 to 6

0.15 to 0.5 mg/kg b.i.d.; up to 40 mg/day

Adderall XR

10, 20, 30

12

Up to 40 mg q am

t.i.d., three times daily; q, every; b.i.d., twice daily.